What’s New in Hand Surgery?

Amy L. Ladd MD Moderator

COA Annual Meeting 21 April 2013

Disclosures None pertinent to this lecture

AAOS website disclosures: Item 1 Royalties from a company or supplier:

Extremity Medical; Orthohelix Item 2 Speakers bureau/paid presentations for a company or supplier:

No Conflict Reported Item 3A Paid employee for a company or supplier:

No Conflict Reported Item 3B Paid consultant for a company or supplier:

No Conflict Reported Item 3C Unpaid consultant for a company or supplier:

No Conflict Reported Item 4 Stock or stock options in a company or supplier:

Articulinx LLC; Extremity Medical LLC; Illuminoss; OsteoSpring Medical, In Item 5 Research support from a company or supplier as a PI: National Institutes of Health (NIAMS & NICHD); OREF

Item 6 Other financial or material support from a company or supplier: No Conflict Reported

Item 7 Royalties, financial or material support from publishers: No Conflict Reported

Item 8 Medical/Orthopaedic publications editorial/governing board: Orthopedics Today

Item 9 Board member/committee appointments for a society: Ruth Jackson Orthopaedic Society

Best Article – practical application

J Bone Joint Surg Am. 2013 Mar 20;95(6):570-4. doi: 10.2106/JBJS.L.01456. PubMed PMID: 23515992.

Amadio annual review

ASSH, AAHS, AAOS 2012 annual meetings

Articles August 2011 – July 2012

Topically based

Skeletal trauma Distal radius fractures ORIF vs. cast in elderly (Shauver JHS Am 2011)

Better x-ray, fewer malunions

Higher complication rates

not cost effective

Skeletal trauma Scaphoid fractures Displaced – ORIF better healing rates, higher

complication rates (Symes, JHS Eu 2011, Singh Injury 2012, Eastley JHS Eu 2011)

Non-displaced – cast works, thumb free is better (ASSH 2012 meeting)

Dupuytren contracture Collagenase vs. needle aponeurotomy vs. surgery

Controversial

Collagenase: least recurrence in MP joints

Needle: high recurrence, but patients like

Surgery: lowest recurrence, highest cost

Quality-adjusted life year (QALY) assessments

Van Rijssen: Pl Recon Surg 2012, Chen: Hand 2011

Nerve Carpal tunnel syndrome

Recovery possible in even longstanding CTS

ASSH 2012

Nerve grafts and conduits

Conduits liked, no science yet

Allograft > 30 mm poor outcome

AAHS 2012

Arthritis Carpometacarpal (CMC) arthritis

Relaxin receptors in surgical CMC ligaments

> in women, with variability

ASSH 2012

Arthritis Metacarpophalangeal (MP) joint implants in RA Comparative study to non-operative treatment – 3 years

Patients preferred it, little functional difference ASSH 2012, Waljee JHS 2012

Proximal interphalangeal (PIP) joint implants in OA Comparative study silicone, titanium, pyrocarbon

Silicone performed best for longevity

High complication rate and reoperation in metal Daecke: JHS Am 2012, Pritsch: JHS Am 2011

Arthritis Distal radioulnar joint (DRUJ) implant arthroplasty

Promising choices, preliminary data

Van Schoonhoven: JHS Am 2012, ASSH 2012

Kienböck disease Type 3B – carpal collapse but no arthritis, many

options, no consensus

Old procedure scaphocapitate resurrected, an option

AAHS 2012

Cost effectiveness of hand surgery Surgical Care Improvement Project measures US hospitals

Use of preoperative antibiotics

For clean CTS/hand surgery not justified (Bykowski: JHS 2011)

2010 Patient Protection and Affordable Care Act

Need for surgeon follow-up?

British study: initial 3 months therapist followup

Suggests not needed for certain conditions (AAOS 2012)

Continuing anti-platelet therapy recommended for surgery

ASSH 2012

Education in hand surgery Fellowship directors study (Davis Sears: JHS Am 2012)

Various responses regarding shoulder, elbow, burn, plexus, microsurgery

Generally one year sufficient

Recent hand fellowship graduates (AAOS 2012)

Inadequate training in shoulder, elbow, plexus, micro

60% preferred 2-year fellowship if offered

Education in hand surgery Microsurgery

Replantation significantly decreased in recent years

Success rate variable

Suggestion for centers of microsurgery rather level I trauma

ASSH 2012, Friedrich JHS Am 2011

Surgical proficiency – objective markers

Flexor tendon lab training – skill retained at 6 mos

Bari: Pl Recon Surg 2012

Distal radius fracture fixation simulated cadaver

No correlation to surgical year or staff rating

ASSH 2012

Conclusions Peter Amadio reports excellent annual summaries

JBJS Specialty Update